Migraine

Pt with h/o headache episodes lasting 4-72 hours presents with unilateral pulsatile/pounding headache accompanied by N/V, photophobia, phonophobia, aura. Headaches occur 4 or more times per month, are disabling, and adversely affect quality of life. No h/o glaucoma, liver disease, kidney stones; denies currently being pregnant. Medications include oral contraceptives. No focal deficits on neurological exam.

  • PRN abortive therapy (select one of the following):

    • Acetaminophen/aspirin/caffeine 250/250/65 mg (Excedrin Migraine) 2 tablets q6 hours; maximum daily dose 8 tablets per day

    • Ibuprofen 600 mg q6 hours; maximum daily dose 2.4 g/day

    • Sumatriptan (Imitrex) 50 mg q2 hours; maximum daily dose 200 mg/day

    • Consider Dihydroergotamine intranasal for refractory symptoms

      • One spray (0.5 mg) in each nostril, repeat once after 15 minutes

      • Do not to exceed 4 sprays per attack, 6 sprays per day, 8 sprays per week

  • Four or more headaches per month that adversely affecting quality of life: Start prophylactic therapy with one of the following (listed most efficacious to least)

    • Depakote 250 mg BID; maximum daily dose 1 g/day

    • Topamax 25 mg qd; maximum daily dose 50 mg BID

    • Propranolol ER 80 mg qd; maximum daily dose 160 mg qd

    • Amitriptyline 25 mg qhs; maximum recommended dose 50 mg qhs due to risk for adverse effects at higher doses

  • Counseling

    • Pt encouraged to keep a headache diary with attention paid to potential triggers

    • Pt counseled that successful treatment is defined as 50% reduction in headaches

    • Pt counseled that prophylactic agents must be trialed for a minimum of 6 months before switching to another medication

    • Pt advised to seek emergency treatment if headache acutely worsens and/or if neurological deficits develop


Notes

  • Etiology

    • More common in women (3:1 ratio)

    • Oral contraceptives may precipitate migraine headaches

  • Common migraine triggers include

    • Schedule changes (sleep disturbances, missed meals)

    • Foods and beverages (alcohol, caffeine, artificial sweeteners, chocolate, soft cheese)

    • Environmental factors (light, odors, smoke, weather changes)

  • POUND mnemonic for migraine:

    • Pulsatile quality (headache described as pounding or throbbing)

    • One-day duration (episode may last 4-72 hours if untreated)

    • Unilateral in location

    • Nausea or vomiting

    • Disabling intensity (altered usual daily activities during headache episode)

  • Prophylactic agents

    • Effective in adults, but not children

    • Start at lowest effect dose and titrate every 2-4 weeks

    • Require 6 to 12 months to reach maximum effect

    • Contraindications

      • Depakote and Topamax: Liver disease, current pregnancy

      • Topamax: Glaucoma, kidney stones

Hemiplegic (Complex) Migraine

Pt with family h/o hemiplegic migraine presents with second occurrence of unilateral headache with aura associated with weakness. Pt reports transient visual field defect, numbness, paresthesia, weakness; all symptoms lasted between 5 to 60 minutes. Witnesses report transient aphasia, seizure-like activity. Afebrile with unilateral motor weakness on exam with ABCD2 score ≤ 3.

  • Obtain FS, BMP, CBC, PT/PTT/INR

  • Consider UDS, RPR

  • Obtain EKG, CT head/neck

  • Consider MRI within 24 hr, carotid doppler within 1 week

  • Treatment

    • Consider neurology consult

    • Start verapamil 240 mg qd in 3 divided doses

    • Refractory symptoms: Consider starting lamotrigine 25 mg qd and titrating to 100 mg qd

  • Pt advised that common migraine treatments (e.g. beta-blockers, triptans, ergotamines) should be avoided

Notes

  • Rare disorder

  • Diagnosis

    • Two attacks must occur before formal diagnosis

    • Aura must be accompanied by fully reversible motor weakness, visual symptoms, sensory symptoms, or speech deficits

    • At least two of the following must occur

      • Unilateral aura symptom

      • Aura symptoms followed by headache within 60 minutes

      • Two or more symptoms in succession with at least one aura symptom spreading gradually over 5 minutes

      • Symptoms last longer than 5 minutes but do not persist for greater than 1 hour for aura symptoms and 72 hours for motor symptoms

  • Beta-blockers, triptans, and ergotamines may predispose pt to prolonged aura or ischemia